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President Bush wants to spend $2.3 billion next year to prepare the nation for a potential flu pandemic. Most of the money would go for stockpiling drugs and vaccines, but that's not what many health experts worry about most. They say that in a pandemic, there would be a severe shortage of intensive care, so some are beginning to think about who would get it and who would not. NPR's Richard Knox reports.
RICHARD KNOX reporting:
Osceola in northern Wisconsin has a population of about 2,700. Alan Hagstrom is pastor of the United Methodist Church there. Lately, he's been thinking about how his parishioners will get critical care when a flu pandemic hits.
Rev. ALAN HAGSTROM (Pastor, United Methodist Church; Osceola, Wisconsin): You absolutely have to discuss this. Undoubtedly the urban hospitals would be full, so we have to figure out how to handle it out in the hinterland and that's one of the big concerns because medical care, health care in the rural areas is already sparse.
KNOX: The Osceola Medical Center across from Hagstrom's church has only 20 beds and no mechanical ventilators to help patients breathe when their lungs are failing. Minneapolis and St. Paul are 45 minutes down the road. During a severe flu pandemic, something like 12,000 people a week there could need hospital care. Thousands would require ventilators to survive, but the Twin Cities have only about 400 according to Dr. John Hick.
Dr. JOHN HICK (Physician, Emergency Planning, Hennepin County Medical Center, Minneapolis, Minnesota): Even a small pandemic of the kind that hit in the 1968-1969 season would be enough to really push our healthcare system into the brink of a crisis, you know, let alone something along the lines of what happened in 1918.
KNOX: Hick is an emergency medicine doctor at Hennepin County Medical Center in Minneapolis. He says America's ICU bed capacity has dropped at least 20 percent in the past decade. It's unrealistic to rebuild that capacity and add enough to deal with a pandemic.
Dr. HICK: We'll have to double or triple or quadruple people's taxes. We would have to expend billions and billions of dollars preparing for things that might never happen.
KNOX: So Hick and his colleagues are trying to launch a debate on a grim topic: How to ration access to precious ventilators.
Dr. HICK: This is a conversation that is just starting, but it's one that we need to have because this would be the first pandemic that will have occurred in the intensive care unit period.
KNOX: These days, Americans take it for granted they'll have access to intensive care, so it may come as a shock to hear about the rationing proposal devised by Hick and Dr. Daniel O'Laughlin. It's published in a journal called Academic Emergency Medicine.
They say a state's governor should declare a healthcare emergency when hospitals can't keep up with the need. That would shift medical care from the best possible treatment for each patient, to the greatest good for the greatest number. That may sound legalistic, but Hick says it's critical. Without that kind of battlefield triage, he says...
Dr. HICK: The system's going to fall apart and chaos is going to develop pretty quickly.
KNOX: Fairness would disappear as individual doctors decided to treat this patient and let that patient die. Under the Minnesota doctor's proposal, all patients without a good chance of recovery would be denied ventilator care. As the pandemic got worse and resources more scarce, the standard of care would tighten.
Ventilators would be denied to people with poor heart function, emphysema and cystic fibrosis, advanced AIDS and cancer, stroke victims dependent on others for personal care. Doctors would no longer be able to say, we did everything we could.
Dr. HICK: Talking to families when the situation isn't that we did everything we could, it's that we could've done more, but we didn't have those resources available--I think that's going to be a really, really hard thing conceptually for the public, for the medical practitioners. But I think it's, unfortunately, just a reflection of where we are with healthcare.
KNOX: Doctors wouldn't just withhold ventilator treatment from people with less chance of recovery; they might need to make painful decisions to withdraw care from people already on the breathing machines. Working out these issues won't be easy says Jeff Sconyers. He's legal counsel at Children's Hospital in Seattle.
Mr. JEFF SCONYERS (Vice President and General Counsel, Children's Hospital and Regional Medical Center, Seattle, Washington): There's going to be a lot of push-back about that. People are going to say, that's not why I got into medicine. I got into medicine to take care of this patient who's here in front of me.
KNOX: Sconyers says government will have to provide legal immunity for caregivers.
Mr. SCONYERS: Hospitals and physicians and others are rightly going to ask, where is my protection. If I follow these rules, what's going to keep A) the patient or the patient's family when the patient dies, from suing me about it and B) the prosecutors from prosecuting me for criminal negligence?
KNOX: Across the continent, New York City officials are deciding whether to buy more ventilators at $30,000 apiece to augment the 2,700 that already exist there. Dr. Marci Layton of the city Health Department says, soon there will be discussions on how to deploy the available machines.
Dr. MARCI LAYTON (Physician; Assistant Commissioner, Bureau of Communicable Disease, Health Department, New York City, New York): Our aim is to have this done way before the pandemic arrives--is definitely what we're aiming for and, you know, it can't be soon enough.
KNOX: These aren't the kind of decisions you want to make, she says, in the middle of a pandemic. Richard Knox, NPR News.
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